Group Motivational Interviewing (GMI) For Homeless Veterans in VA Services

描述（由申请人提供）： 对退伍军人医疗保健的预期影响：退伍军人事务部制定了一个雄心勃勃的目标，到2015年结束退伍军人无家可归的情况。HUD-VASH和格兰特和每日津贴（GPD）是两个主要的VA住房计划，以帮助退伍军人退出无家可归。VA住房中的退伍军人药物滥用是精神病理学恶化和住房不稳定的主要风险因素。尽管最近通过了住房第一的方法，许多VA住房计划缺乏管理物质使用障碍（SUD）的工作人员基础设施。这是一个重要的问题，因为60%（保守估计）的退伍军人在VA住房有SUD，这些退伍军人表现出更大的精神病理学相比，他们的同行没有SUD。这些问题保证了对VA住房中SUD方案的大量需求，这些方案部署效率高，易于分层到现有服务中，并且需要最少的工作人员来操作。目前的研究解决了VA治疗服务中的这一空白，它调查了动机访谈的适应性治疗的有效性，实施过程和成本估计，这是一种经验支持的干预措施，对减少物质使用和提高治疗参与度具有强烈影响，以小组形式，被称为小组动机访谈（GMI），用于VA住房中患有SUD的退伍军人。该项目的数据，如果被证明是有希望的，将建立一个GMI传播和执行行动方案的基础，为高度脆弱的无家可归的退伍军人在弗吉尼亚州的住房，以实现他们在实现住房稳定的最大成功。背景：有一个显着的需要，在VA住房解决SUD的“环绕”治疗服务。患有SUD的无家可归退伍军人容易出现治疗辍学，使他们容易复发，而他们在参与VA住房期间继续接受门诊治疗会改善临床结局。根据系统评价，与未治疗相比，个体MI降低SUD的发生率，但劳动强度大。随着VA走向“住房第一”的范式，更多无家可归的退伍军人将继续使用物质，而在VA住房，交付GMI（这可能是劳动密集度较低），这些患者将是重要的启动和维持他们的恢复，以及提高他们的心理社会融合和生活质量。 在PI之前进行的一项对照试验中，与双重诊断的退伍军人中的常规治疗相比，GMI导致门诊治疗参与率显著提高，物质使用率降低。目的：研究目的与VA住房建议一致，重点关注患者康复、健康服务促进和治疗实施评价。将GMI与对照治疗条件（CT）进行比较（具体目标I;五个结果：（主要H1）：治疗参与;（主要H1）：物质使用;（次要H2）：心理社会整合（例如，社会支援、社区参与）;（中H3）生活质素/精神科指数;及（中H4）：在6个月的跟进期内，参与有系统/生产性工作活动的日数。具体目标II涉及记录（A）形成性（例如，具体目标III涉及从直接成本、工作人员间接成本、资本成本和未来实施和传播研究的工作量措施等方面估计干预成本。方法：随机对照试验比较GMI和CT在五个关键结局方面的差异。将入组186名VA住房服务的退伍军人（每个治疗组93名），诊断为酒精或药物滥用/依赖。招聘将在查尔斯顿VAMC HUD-VASH & GPD进行。受试者将被随机分配到（1）GMI或（2）CT，每个包括4个疗程，并将在1、3和6个月时进行评估。患有非物质相关DSM-IV-TR主轴I障碍的参与者（例如，MDD、PTSD）将有资格参加本研究。将使用广义线性混合模型（GLMM）方法进行分析。

DESCRIPTION (provided by applicant): Anticipated Impacts on Veterans Health Care: VA set an ambitious goal for ending homelessness among Veterans by 2015. HUD-VASH and Grant & Per Diem (GPD) are two primary VA housing programs to help Veterans exit homelessness. Substance abuse among Veterans in VA housing is a major risk factor for worsening psychopathology and housing instability. Despite recent adoption of a Housing First approach, many VA housing programs lack the staff infrastructure to manage substance use disorders (SUDs). This is a significant problem as 60% (conservative estimate) of Veterans in VA housing have SUDs and these Veterans show greater psychopathology compared to their counterparts without SUDs. These issues warrant substantial need for SUD programs in VA housing that are efficient to deploy, easily layered onto existing services, and require minimal staff to operate. The current study addresses this current void in VA treatment services in that it investigates the effectiveness, implementation process, and cost estimate of treatment of an adaptation of motivational interviewing, an empirically supported intervention with strong impact on reducing substance use and enhancing treatment engagement, in a group format, referred to as Group Motivational Interviewing (GMI) for Veterans with SUDs in VA housing. Data from this project, if shown to be promising, will establish the basis of a GMI dissemination and implementation course of action for highly vulnerable homeless Veterans in VA housing for achieving their greatest success in attaining housing stability. Background: There is a significant need for 'wraparound' treatment services in VA housing for addressing SUDs. Homeless Veterans with SUDs are vulnerable to treatment dropout, rendering them susceptible to relapse, while their continuation in outpatient care during their participation in VA housing leads to improved clinical outcomes. According to systematic reviews, individual MI reduces the incidence of SUD, when compared to no treatment, but is labor intensive. As VA moves toward a 'Housing First' paradigm where greater numbers of homeless Veterans will continue to use substances while in VA housing, delivery of GMI (which may be less labor intensive) to these patients will be important for initiating and maintaining their recovery as well as enhancing their psychosocial integration and quality of life. In a prior controlled trial conducted by the PI, GMI resulted in significantly higher outpatient treatment engagement and lower substance use compared to treatment-as-usual among dually diagnosed Veterans. Objectives: Study objectives are consistent with VA housing recommendations focusing on patient recovery, health services promotion, and treatment implementation evaluation. GMI will be compared to a control treatment condition (CT) on (Specific Aim I; Five outcomes: (Primary H1): treatment engagement; (Primary H1): substance use; (Secondary H2): psychosocial integration (e.g., social support, community participation); (Secondary H3) quality of life/psychiatric indices; and (Secondary H4): number of days engaging in structured/productive work activities in the 6-month follow up. Specific Aim II involves a process evaluation for documenting (A) formative (e.g., developmental), (B) process, and (C) summative outcomes; and Specific Aim III involves estimation of cost of intervention in terms of direct costs, indirect costs of staff, costs of capital and workload measures for future implementation and dissemination research. Methods: Randomized controlled trial comparing GMI to CT across five critical outcomes. 186 Veterans in VA housing services (93 per treatment arm) will be enrolled with a diagnosis of alcohol or drug abuse/dependence. Recruitment will take place in Charleston VAMC HUD-VASH & GPD. Participants will be randomly assigned to (1) GMI or (2) CT, each consisting of 4 sessions, and will be evaluated at 1, 3, and 6 months. Participants with a non-substance related DSM-IV-TR major Axis I disorder (e.g., MDD, PTSD) will be eligible for the study. Analyses will be conducted using generalized linear mixed models (GLMM) approach.